Episode 109 Transcript: Partnering with White Ribbon VA
Greg Wright:
Welcome to Social Work Talks. I'm Greg Wright. Today we are here talking about domestic violence and White Ribbon VA, an initiative to eliminate sexual harassment, sexual assault, and domestic violence across the Department of Veterans Affairs. Domestic violence continues to be a serious problem in the United States. According to the National Coalition Against Domestic Violence, 1 in 20 people in our nation are physically abused by an intimate partner every minute. That adds up to 10 million men and women each year. We have some of the leading experts on domestic violence here today. They also represent organizations that are partnering with White Ribbon VA. Let me introduce.
The first is Dr. Bridget Truman. Dr. Truman is Associate Director of the Prevention and Management of Disruptive Behavior at the Veterans Central Office, Office of Mental Health and Suicide Prevention in Asheville, North Carolina. Our second guest is Dr. Angela Lamson. She is a professor at East Carolina University and a representative of the American Association for Marriage and Family Therapy. Dr. Carole Warshaw, MD, is director of the National Center on Domestic Violence, Trauma and Mental Health. We may also have another guest, social worker, Dr. Tricia Bent-Goodley with us later on. She actually has a client now who is having a crisis and may join us in a few. She is a National Association of Social Workers expert, and also an author on this subject. Welcome to Social Work Talks all.
Bridget Truman:
Thank you.
Carole Warshaw:
Thank you.
Greg Wright:
So, our first question is, this is a very complicated and emotional topic, and I wanted to ask you, how were you drawn into this? How did you end up addressing the issue of domestic violence? I'll ask Ms. Lamson first, and then after that, Ms. Truman.
Angela Lamson:
Sure. Thank you, Greg. So, as a part of my role at East Carolina University, I have been a part of a medical family therapy doctoral program. In medical family therapy we see health as a part of illness, loss, trauma, death, and in the context of families, and how those families interface with their healthcare systems, their school systems, their justice systems, military systems. And so for me, I am drawn to begin thinking about how relationships matter. And being able to think about facets of domestic violence, as we also consider how to intervene both through trauma-informed treatments, and also focusing on resilience in relationships.
Greg Wright:
Thank you. Bridget, or should I say Dr. Truman?
Bridget Truman:
Oh, feel free to call me Bridget. Happy for you to do that. Yeah. So, I became interested in this as just a lifelong career, and looking at working with individuals who have experienced different forms of trauma. I started my career in crisis intervention and have continued with that with the VA. Currently I serve as the associate director, as you mentioned, for a employee education program that's within VA, that really helps to target any types of workplace violence. And so, certainly domestic violence can spill over into our workplace settings. And so, I've just continued my interest in making sure that we equip our employees with the tools to be able to navigate these challenging situations.
Greg Wright:
Thank you. Dr. Warshaw, our question is, what actually drew you into a career that addresses the issue of domestic violence?
Carole Warshaw:
Oh, that's a long question. Thank you. So, I started working on domestic violence in 1980 when I was an ER physician at Cook County Hospital, and we did a journal club when there were only a few articles. I was already thinking about issues of violence against women and women's health, on people coming to emergency rooms who experienced domestic violence, and nobody was addressing them. Particularly Evan Stark and Anne Flitcraft's really important article on patriarchal violence, and looking at how people would come to the ER, and nobody would figure out what's going on. And they come back with all the complicated problems related to domestic violence ongoing, where no one's intervening. And then, all of the tragic consequences that are potentially there if nobody pays attention.
So it's really about the healthcare system not responding that was part of the problem. So we did a study that was published in 1989, looking at ER records where nobody was looking at what was really going on. It was like hit by fist or jack hammer, nobody was attached to the fist, nobody was. So a lot of my work has been, what is it about the medical system that mitigates against people actually recognizing what's happening, and being able to be present and empathic, and take in and respond appropriately? So, I was doing this work in the healthcare field for many years, and then went back and did a residency in psychiatry. And was really looking at all of the complex layers of what goes into people's experiences and the system responses or lack of system responses.
So, in 1993 we started on the first hospital-based domestic violence advocacy [inaudible 00:05:56] at Cook County Hospital. And in 1999 we started doing work on the mental health and domestic violence. And again, we're working with all the DV programs in the Chicago area and the publicly funded health system, and people were beginning to understand trauma but not about ongoing risk and coercive control. And then we became a Federally funded national center in 2005. And so our work is to really support the DV field in responding to mental health, and substance use, and trauma related needs of survivors and their families, and to help their organizations be accessible, also responsive trauma [inaudible 00:06:34], and to try to improve the responses of the mental health and [inaudible 00:06:38] systems.
As well as other systems where mental health and substance abuse are used against survivors, like child welfare, family court, and the criminal legal system. So I'll talk a little bit more about this complex intersection, but part of our work is looking at what happens at the individual level, but what happens at the societal level, and what happens at the political level that creates structures that really help perpetuate abuse and violence.
Greg Wright:
Thank you.
Carole Warshaw:
Sorry.
Greg Wright:
Oh, no, no, no, not at all. Now, one thing that I've learned, I work with social workers is that, this is an issue, it cuts across class, race, face, it's everywhere, even though it's hidden a lot. Dr. Warshaw, I wanted you to give us an overview about how widespread this issue is, and also why isn't it that open? Why is it so hidden in our society?
Carole Warshaw:
Well, first of all, I know how many of you're familiar with the CDC's NISVS Study, the National Intimate Partner and Sexual Violence Study that they do. And the most recent data is from 2016, 2017, and their latest publication was from October of '22. So, the statistics keep getting updated. But more than half of women, 54.3%, nearly one third of men, 31% in the US, reported some form of sexual victimization involving physical contact, or sexual violence at some point in their lifetime. And almost 1 in 2 women, and more than 2 in 5 men reported experiencing contact sexual violence, physical violence, and/or stalking by an intimate partner at some point in their life. That's a lot of people. And about 2 in 5 women and 1 in 4 men in the US experienced some form of intimate partner violence that had a major impact on them for example, [inaudible 00:08:41], or the sense that they see a need to have legal services or help from law enforcement.
One of the things that's important to understand, and there are also very high rates among LGBTQ individuals, high rates of [inaudible 00:08:53] and particularly Black kids, transgender women, disproportionate impact on many communities that have been marginalized. And part of that is due to structural violence and the lack of resources, and ways that society respond to these very [inaudible 00:09:17]. I was just going to say, it's also important to address the impact of intersectional discrimination and bias on the basis of gender, race, and other factors, including sexual orientation, ethnicity, immigration, religion, disability, age, and socioeconomic status. So part of what people who abuse their partners do is, leverage anything that they can that creates vulnerability or risk for someone. Because they know that's someone that they can view as a legitimate target, or they know that certain forms of abuse are going to make it much harder for them, because of discrimination in society, for example.
Greg Wright:
Thank you, thank you. Dr. Truman, so, all of your organizations are partners with a White Ribbon VA. And I was wondering if you could explain exactly what that is? I work for the National Association of Social Workers. I mean, we've been a partner for a few years. How long has your... Well, you're a part of the VA, so, explain it, and I want others to answer, why are you now a partner with them? Thank you, Dr. Truman.
Bridget Truman:
Yeah, Greg, thanks so much. That's a great question. So the White Ribbon VA campaign was launched initially in 2020 by the VA, really in an effort to help veterans and employees feel welcome, and physically and emotionally safe at all VAs. It really was linked to our mission to provide excellent healthcare for our veterans, and resources for their families. So as you mentioned, we partnered with the White Ribbon USA, and the National Association of Social Workers, to really have this shared goal of taking an active stand and ending sexual harassment, sexual assault, and domestic violence. What we really want to emphasize is that, the White Ribbon VA campaign really is the department's national call to action to eliminate sexual harassment, sexual assault, and domestic violence across VA.
And really attempting to promote a positive change in culture, so that the actions outlined in the pledge become the organizational norm. What's really exciting is to date, we have more than 300,000 VA employees, veterans, Congressional members, and our partners in interagencies and communities have all taken the White Ribbon VA pledge. At this point we have 100% of our VA medical facilities who have a White Ribbon VA champion. So this is someone at the facility who's going to lead the way in getting the word out about the campaign and the pledge. And we've interwoven it into a lot of our VA programming system-wide, including the swearing in that we have with the senior executives, with the Secretary of the VA.
So they take this pledge as part of their swearing in ceremony. We've also included it in our prevention and management of Disruptive Behavior Training program, as well as new employee orientation. And we're really excited to share that. On December 1st, there'll be a White Ribbon Day in Congress, and this is an opportunity for us to recognize survivors of domestic violence. We have a whole host of speakers, one of which will be Veronika Mudra, who is the founder of the White Ribbon USA program.
Greg Wright:
Excellent. Dr. Lamson, why is your organization involved? What actually prompted that?
Angela Lamson:
Well, we're so excited with AAMFT to be a part of the White Ribbon Program. And I feel like our missions are very much aligned. And so, that to me is such a call, not only to the organization, but to our providers to engage and to be reminded of the importance of this mission as we provide training and education to our next generation of learners, to be proactive as clinicians. And that means a lot of things. Because our clinicians in marriage and family therapy are situated across the lifespan, thank goodness. Because of different forms of insurance, and also being able to provide for uninsured, we're able to be able to see people in medical contexts, in spiritual contexts, in private practices and agencies. And so, I think a lot of what is important for us at AAMFT is that, we are not going to stay silent.
We are going to be committed to addressing issues of sexual harassment, and sexual assault, and domestic violence. And so, I am grateful for our code of ethics as well. It's challenging, it's challenging work. Even though we are marriage and family therapists, a lot of who we see are individuals, and we see those individuals systemically. We see them within their relationships, and we also see their biological, psychological, social and spiritual health. And so, it's important for us at AAMFT to honor our relationship and our contributions with White Ribbon. We will be a part of the December 1 event. And so, we're excited about that. We are also going to be featuring some articles on the aamft.org website that may be helpful for others to be able to see as well, in relation to family couple, and family therapy and domestic violence.
Greg Wright:
Dr. Warshaw, your organization has been around a long time, but what actually drew you into a partnership with a White Ribbon VA at this point?
Carole Warshaw:
There've been people within the APA who have been very committed to addressing issues of intimate partner violence, in the context of mental health treatment, and substance use disorder treatment. One of the things that they did, there was an online diet for psychiatrists on intimate partner violence that a number of us were involved in. So that's there. We recently developed tele-psychiatry guidance. So that people who are providing telehealth or tele-mental health or tele-psychiatry can recognize the potential safety risks for someone who's abusive partner is trying to monitor their calls, or put spyware on their technology. Or who is trying to interfere with their treatment or access their medical records through and in a portal.
So, we've been doing work on that. We've done lots of trainings at annual meetings. And the committee on [inaudible 00:15:45] mental health center [inaudible 00:15:46] becoming a council, which gives it more influence within the APA. The APA used to have committees on family violence and childhood trauma, and I think this will be another way to raise that to another level within the APA. The APA also supports Federal policies that really impact lots of people who experienced intimate partner violence and data-based violence in general, including the national action plan on gender-based violence.
Greg Wright:
Thank you. So, all three of you doctors come from professions that are kind of related, because you're all about mental wellbeing. So I wanted to ask, how does each of the professions address this issue? Is it different, or is it similar, how you approach and treat a client? Anybody who wants to answer, answer that please?
Angela Lamson:
How about I'll take a go and then my friends can join in? Honestly, I think that all of our mental health professions are needed. And the ways in which clients, patients, customers, residents, however you want to consider the individuals that come to us, if they find us, we are grateful. And I think when we are in these roles, if we feel as though the needs that they bring to our attention are not in our wheelhouse, we are going to be collaborators to work with one another, to ensure that that individual's needs, or that couple's needs, or that family's needs are met. So for me, I do think that we need to spend a lot of time in our joining process with those that come to see us. We recognize that when there's domestic violence that's a part of someone's life, it is difficult to know how to trust a provider.
It is difficult to know how to open up and address what's happening in their life. And so, I think the joining process is incredibly invaluable. And hoping then that we can discern how to best assess what's happening. Because domestic violence can influence our life physically. It can influence our life psychologically. It can influence our life socially. It can influence our life spiritually. And the questions that we ask can go in a variety of directions. That also means, as providers we have to be very aware of what we're hearing. We may need to listen for cues differently. And I know Dr. Warshaw mentioned a lot of different intersectionalities. When I'm working with Hispanic women, I may be listening for different kinds of experiences, for example. So I think, engaging in our joining, engaging in our assessment, helps us with our interventions to make sure they're indicated.
And that can be really complex for a marriage and family therapist. But I have some incredible colleagues who are working very hard to provide us with indicated and evidence-based treatments that can help individuals as well as couples and families. And I don't want to dismiss the importance of focusing on children who witness domestic violence. And so, adverse childhood experiences is essential to the work that I do. And too frequently we're asking questions in healthcare context, but we're not necessarily clinically following up with what happens with those questions. And so, I just think that we need to be mindful of those aspects. But, turning to my colleagues in social work, in counseling, in psychology, psychiatry, those are incredibly important partners. As are the pediatricians and primary care providers, and oftentimes spiritual leaders as well. Thank you.
Greg Wright:
Yeah. Thank you. Dr. Warshaw, did you want to weigh in on how your profession addresses this, that might be a related way, or different from how the others do?
Carole Warshaw:
Well, it's hard to generalize, because in psychiatry people do so many different things. Some people are more psychopharmacologist, and other people do therapy, and some do a combination, some work in private practice, some in other larger settings. So there's quite a range. So there's all of the things that are kind of standard for doing culturally responsive trauma-informed work. And how, one of the things, is all the stuff around screening and assessment, and really how do you create a safe space for someone to talk about what's happening in their lives in ways that they feel safe and comfortable doing that. And as you said, Angela, building trust when trust has really been betrayed. Whether it's childhood trauma, or from an intimate partner violence, or a system, that can be challenging, and recognizing that is really critical.
Part of what we focus on is both, what are the unique risks of someone who's experiencing intimate partner violence experience? And I was going to talk about it earlier. There are very high rates of mental health effects of high rates of people experiencing intimate partner violence, and mental health and substance use disorder treatment settings. And researchers consistently documenting the mental health and substance use related effects of IPV, and of course, abuse and violence across the lifespan. But one of the things that's less well recognized is forms of abuse that are specifically targeted towards a partner's mental health or substance use, that we've coined mental health and substance use coercion. And we did two national surveys in 2012, and we've just repeated one that we were analyzing the data.
But there are a very high percentage of people who said that their partners deliberately did things to undermine their sanity, gaslight them, interfere with their treatment control, their meds, try to prevent them from accessing services. In substance abuse there were 27% who said they were coerced to use by an abusive partner. And of the 15% who saw treatment, 60% said their partners tried to prevent them from access treatment or diverting meds. And then they would turn around and use it against them to undermine their credibility with potential sources of protection and support. So, if for mental health and substance use disorder, treatment providers not to recognize what's going on, for example, someone's buprenorphine level is too low, so what if they're not complying when their partner is diverting their meds, or they're using something else. They're going to get drug tested and lose their kids because their partner's forcing them to use.
So, lots of things that people need to be aware of. So we have a whole layer of how to intervene that people usually don't think about. And even things like open notes, where the default is that your information's going to be available online when your abusive partner may try to access that, and all the things you have to put in place to block that, if that's going to be dangerous for people even to talk about that. Or, if you have a psychiatric advanced directive, who's the attorney, in fact, who's making decisions for you. So there's lots of layers of things that need to get integrated in addition to the trauma treatment, or adding that layer into any kind of treatment that really looks, is someone that's still at risk? And how do you heal when you're still under siege? So there's a lot of layers, but I'll stop.
Greg Wright:
Oh, yeah, yeah, definitely. Dr. Truman. So, you are working in a military setting. I was wondering, is it a culture that differs? For instance, Dr. Lamson said she has a client who is a woman who is Hispanic, so there are things to listen for. Working with a military client, are there things that are specific there that you might want to tell us about?
Bridget Truman:
Sure, Greg. I think that's a great question. So, when we think about our veterans in this particular population, there can be higher prevalence of PTSD and traumatic brain injury. Which can then in turn increase the potential for the prevalence of domestic violence to occur. And certainly, when we think about higher rates of violence in a veteran population, more so than a civilian, there has more potential for that cause of significant injury. I think it's important to recognize how veterans may feel, especially when they come from a military culture where they may have not gotten a lot of support about seeking mental health services, or addressing substance abuse issues. Which as Dr. Warshaw mentioned, could be a risk factor for domestic violence. So that fear and that concern can travel with them when they're out of the military, and now they're in the veteran population.
Sometimes that can make them even more anxious to talk about these issues, to talk about these concerns and to seek treatment. So I think, we really have to pay attention to, as Dr. Lamson mentioned, some of those more subtle cues that this type of experience is happening for them, so that we can really do what we can to support them in getting the services that they need, and the support that they need. We've got a really great... In 2014 we had established the intimate partner violence prevention assistance coordinator. And so, this is a person that is at VHA facilities, that really is able to provide services for veterans, for family members, and even for employees who've experienced intimate partner violence, to get them to the therapy, and the resources and the treatment that will help them along that healing journey.
Greg Wright:
Excellent, excellent. So, a few more questions. One is... Oh, absolutely, absolutely.
Carole Warshaw:
One of the things that's really important is being able to build partnerships with domestic violence programs, and to be able to have those, not just send someone off, but a really warm referral, people being able to make calls while they're in your office. And also being able to do cross consultation for providers who aren't champions, to get to a place where they're more comfortable, and have those relationships. So there's lots of ways to do that, but it's really a critical piece that I wanted to [inaudible 00:25:37].
Greg Wright:
Yeah. So, is there more of that happening now, where there's more cross partnerships with all of the local resources? I mean, is it more open now than it's been? Whoever wants to answer that, I would love to know.
Carole Warshaw:
I know there are a lot of places that have onsite domestic violence programs, or gender-based violence, human trafficking, sexual assault, DV programs. Some that have partnerships with local programs, some that have their own experts onsite, who can then make a referral if somebody needs shelter, or needs other kinds of things that aren't available, or who need legal assistance. So there's lots of ways to figure out what the best mix is. But depending on resources in your community and in your setting.
Angela Lamson:
I was just going to add to that, but I do think that there is a beautiful growth in integrated care, and that is the concept of having different kinds of providers to work together, sometimes simultaneously on behalf of patients and/or clients. And so, I think being able to have physical health, and mental health or substance use treatments happening simultaneously with one another helps in so many ways. I think too, it provides a teamwork with the client or patient, and not on the client or patient, if you will. It really helps them to have a voice and agency in what they feel is going to be needed for themselves and for their families. And I think that in and of itself can help to build trust. It's like being able to say, "Dr. Warshaw and I, we work together oftentimes." So being able to build that teamwork with the client, or the patient helps to provide that safer environment for future care.
Greg Wright:
Thank you, thank you. Another question is, if I'm a person who is experiencing like this, I was wondering if each of you could offer some resources for help. And we also have our resources that we'll post up under this episode. So, even if you say it fast, we'll be able to record it and share it with our audiences. So whoever wants to go first, it's up to you.
Carole Warshaw:
I could do the hotlines. There's a National Domestic Violence Hotline that's 1-800-799-SAFE, and they also have a TTY and a text. So, then there's a National Teen Dating Abuse Hotline, that's 866-331-9474, and the text is 22522. And then there's the Strong Hearts Native Helpline, that's 844-762-8483. There's also the National Sexual Assault Hotline and the DOD self-help line for sexual assault and human Trafficking hotline.
Greg Wright:
Thank you, thank you. Any others? Doctors, doctor or doctor? I have never been on an episode with three doctors at the same time. We would've had four, so I'm impressed. That's a major accomplishment. Dr. Lamson, any other resources that you can think of?
Angela Lamson:
I will say one that I do share. Obviously, I think it's important for us to be thinking about our more local resources as well. And so, being able to think about for our children, knowing that the school oftentimes is that resource, where you may be able to have a protected conversation. Our primary care offices are really an entrance point as well, oftentimes for mental health and substance use as well. For me, I always want to make sure that people know the 988 number. And while that is most commonly aligned with suicide, it is important we screen every single individual for suicide. Because we know how desperate situations can become with regard to domestic violence as well. And if they are not able to seek help in one way, we're going to hope that they seek it in another.
Greg Wright:
Thank you. And, Dr. Truman, you are at the VA. You have already mentioned that you have help at a VA center. Could you kind of run through that once more please?
Bridget Truman:
Sure. Happy to do so. And just want to tag into what Dr. Lamson was saying, that with our veterans, really you want to make sure that they have that 988 number, and then veterans will press one to reach the veterans crisis line. So that's another tool that they can have. As I mentioned before, we have had since 2014, the intimate partner violence assistance program coordinator. We also, in recent times have added harassment prevention coordinator at VHA sites, that will manage any kind of reports and get folks access to care. I think the main thing that we really try to do at the VA is, remind our veterans of all these points of access to get to appropriate medical and mental health resources.
So they can talk to the VA police, they can talk with our patient experience officers. They can even talk with their primary care physician, and they will get them connected to the proper resources. We've also had for many years now, the military sexual trauma coordinator. So this is someone who's specially designed to make sure that the veterans get access to care, and get access to therapy when they've had those types of experiences in the military.
Greg Wright:
Thank you, thank you. I also want to chime in that the National Association of Social Workers has a website called healthstartshere.org, and it has a lot of resources there, including many of the lines already mentioned by Dr. Warshaw and Dr. Lamson. So, it's been a wonderful conversation. The folks in our audience don't like... No, this is probably our biggest panel on a podcast ever. Usually we only have a single guest or two guests. Today I have three, and I could have had four. These are all accomplished and busy people, so I thank you for having a little time for us. I know that it was a big deal to get us all together in one place at one time. So, a final question is, how can all these different professions and organizations work with each other better? If you could offer that, then I'll let you go, so that you can get ready for the holiday coming up. So...
Bridget Truman:
Yeah. Greg, I think that's a great question. And I think just to reiterate, with the White Ribbon VA Initiative, our partnership with the National Association of Social Workers and the White Ribbon USA program, really demonstrates a great example of a shared goal to eradicating sexual violence of any kind and domestic violence. And we really recognize and see that resources and supported services are available to anyone who's experienced sexual violence. We're really excited, as Dr. Lamson had mentioned that the American Association of Marriage and Family Therapy is joining us on December 1st. We're really excited that the American Psychiatric Association has joined our efforts as well. We really do believe that we can stand together and help to eradicate these types of violence from occurring.
Greg Wright:
Thank you, Dr. Lamson or Dr. Warsaw, whoever wants to go.
Angela Lamson:
I'm so grateful for Dr. Truman's comments. And I would say that, one of the things that would be helpful for all of us, is to continue to collaborate clinically, to continue to collaborate on policy. And that's something that I've really been keeping an eye on recently as we think about prevention, as we think about protective factors, and the influence on children to end domestic violence, to end intimate partner violence. And so to me, being able to think about our work clinically, being able to think about our work through policy, through research, et cetera, together, I know that we can do better together.
Greg Wright:
Thank you. And Dr. Warshaw?
Carole Warshaw:
I think I have to echo what both of you have said. But I think it's really making sure there's more formal opportunities for pooling resources, and thinking about where we're doing things that are similar, where our work amplifies each other, particularly on the policy front. And the other is on how do you, even when you have things that are in Federal policy, implementation on the ground requires a lot of resources and a lot of support. And we know from what it needs to do, trauma-informed work, that staff really needs support. And trying to really think about what does it take to have that happen on the ground is going to be really important. So, I welcome the opportunity of all of our organizations working together more.
Greg Wright:
Thank you, thank you.
Angela Lamson:
If can add one more that's [inaudible 00:34:39]-
Greg Wright:
Absolutely, absolutely.
Angela Lamson:
Together, we have unified through COVID. We have unified through many social injustices. And I think we've got a lot of providers who have also experienced, or are currently experiencing domestic violence. And so together I think too, to be able to care for one another, to look out for one another as we care for those who are experiencing domestic violence.
Greg Wright:
Thank you, thank you. Well, I want to thank Dr. Lamson, Dr. Warshaw, and Dr. Truman for being our guests today on Social Work Talks. Thank you very much now.
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